Background/Purpose: Centers for Disease Control and Prevention Guidelines recommend that all immunosuppressed patients receive the pneumococcal vaccine. The American College of Rheumatology Task Force Panel recommends vaccination for patients initiating therapy with disease-modifying anti-rheumatic drugs (DMARDs) or biologic therapies. Patients with chronic rheumatologic conditions have approximately double the incidence of infection compared to the normal population and those taking immunosuppressive agents show the highest risk, with the majority involving respiratory tract infections by common pathogens including S. pneumoniae. Prior studies show the rate of pneumococcal vaccination is low in this population. The aim of this study was to improve both administration and documentation rates of pneumococcal vaccine in immunosuppressed patients taking DMARDs and/or biologic agents at a university-based rheumatology clinic. 

Methods: This study is a pre- and post-intervention comparison. Intervention phase data was collected from 1/23/2012 – 6/15/2012. Pre-intervention data included patients seen between 1/1/2009 – 12/31/2010 that were prescribed an immunosuppressive medication. Regularly seen patients were defined as having at least 2 visits, with either 1) at least 1 visit within the first 12 months of the measurement period and at least 1 visit within the second 12 months, or 2) 2 visits within only the second 12 month measurement period, with the first and last visits being separated by a minimum of 90 days. Patients eligible for pneumococcal vaccine and patients who were up-to-date with pneumococcal vaccination were determined. For the intervention phase, a report was generated of patients on immunosuppressant medications who had not received the pneumococcal vaccine who had upcoming visits. Clinic staff flagged these patients and a pneumococcal vaccine information sheet along with a brief form for the patient to complete were given to the patient. The medical assistant (MA) gathered information and documented in the electronic record. The MA communicated to RN who ordered and administered the vaccine. In select cases, physician approval and order were required prior to vaccination.

Results: Baseline data included 968 patients. Only 148 (15.3%) patients had received the pneumococcal vaccine. Post-intervention pneumococcal vaccination compliance revealed 361/1044 (34.6%) of patients had received the vaccine. This was a significant improvement from baseline (p<0.0001). An additional 114 (10.9%) patients were offered vaccination but had either already received the vaccine or deferred. A total of 45.5% had documentation, which was also significant improvement from baseline of 15.8% (p<0.0001).

Conclusion: Pneumonia vaccination administration rates in immunosuppressed patients with rheumatologic diseases are low and do not meet published guidelines. Implementation of an e-record and ancillary-staff-based intervention significantly improved vaccination and documentations rates without the need for considerable physician input. Ancillary staff review and physician communication were the key components in improving compliance with vaccination.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/improving-pneumococcal-vaccination-and-documentation-for-immunosuppressed-patients-at-a-university-based-rheumatology-clinic/